Laserfiche WebLink
WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL ZU9 953-Ib9/ FOR INSPECTIUN5 cArlrtw I /ittA,N rnUFVILJAJII/v raavcu <br />JOB ADDRESS CITY y ( I <br />j <br />iCROSS STREET nwV�" PN ��/ PARCEL SIZE �� • LAND USE APPLICATION # <br />,OWNER NAME l� �. �� ` 7 bin!—)" ) P O <br />(OWNER ADDRESS r CITY/STATE/ZIP �� <br />CONTRACTOR <br />r <br />CONTRACTOR ADDRES <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 F) C-61 <br />(l D-09 [I Other <br />CITY/STATE/ZIP Vf ,1\-A / r <br />PHONE <br />1 / T I /f/ � <br />NUMBER EXPIRATION DA <br />VICV Vl1Mrn1VNL 11Yr......V.. VVVIVIt1iILUM A I IVW11W11j! n011VC OCVIIVII <br />INTENDED USElOestic/Private C7 Irrigation/Agricultural ri Industrial ,:, Water Quality Monitoring U Soil Sampling/Characterization <br />�,_Irn Public Water System <br />If different from Owner: Water System Name------- C—ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well l I Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical If of borings <br />❑ Out-Of-Servic ll U Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />11 New Pum kump Replacement U Pump Repair [7 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool U Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom [� Gravel Pack/Gravel Size in diameter <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic C Stainless Steel 0 Other <br />Grout Seal Depth ft C' Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mhd7 gal water <br />[.I Bentonite (20% solids) 1 Other <br />Grout Placement Method Ll Pumped ❑ Free Fall U Other [ I Retardant / Accelerator (name) <br />PEDESTAL Installed By U Driller 7 Pump Contractor ❑ Other <br />Concrete Pedestal 1: Dimensions: Width ft Length ft Thick in D Christy Box 11 Stove Pipe <br />PUMP'Vi Submersible(I Turbine I i Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKEftrk COMPENSATION LAWS. <br />c <br />.�i <br />m <br />D <br />v <br />v <br />m <br />m <br />rn <br />N <br />Area Employee ID#7:2�W-. / <br />0 SPECIAL Well Permit is 4t�vl`Y <br />L WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />r 1 <br />4 .L Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />ti Date I <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />.�i <br />m <br />D <br />v <br />v <br />m <br />m <br />rn <br />N <br />Area Employee ID#7:2�W-. / <br />0 SPECIAL Well Permit is 4t�vl`Y <br />L WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />ReceivedChe <br />B <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />r7 <br />I'o <br />EHD 43-06 WELL/PUMP PERMIT <br />4/30/12 <br />